Avir at Dallas

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences one (Resident #1) of one resident reviewed for quality of care. The facility failed to ensure Resident #1's oxygen liter flow rate matched the physician's orders. This failure could place residents at risk of not receiving appropriate treatment and care, and decreased quality of life and overall health.

Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 (Resident #1) of 3 resident's reviewed for discharges. The facility failed to ensure Resident #1 had dialysis services approved on 7/29/2025 before Resident #1 was discharged from the facility. Social Worker A was informed by the dialysis center that Resident #1 was not approved for their services prior to Resident #1 being discharged . Social Worker A did not delay the discharge until dialysis services were arranged for Resident #1. Social Worker A failed to notify the facility staff of Resident #1's dialysis denial. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed on 07/23/2025 to ensure food items in the facility walk-in refrigerator was dated. 2. The facility failed on 07/23/2025 to ensure the seasoning containers were tightly covered.3. The facility failed on 07/23/2025 to ensure the top and back of the oven was clean and free from debris and dust.4. The facility failed on 07/23/2025 to ensure the ice making machine was free from leaks and accumulation of scale. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when doing so would endanger the health or safety of the resident or other residents for 1 of 23 residents (Resident #33) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light device was within the reach of Resident #33 on 07/21/2025 when the resident was lying in bed in his room. This failure could have placed residents at risk of being unable to have a means of directly contacting the caregivers.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Residents #1 & #2) reviewed for care plans. 1. The facility failed to develop a comprehensive person-centered care plan that reflected Resident #1's diet was a puree diet as ordered on 07/10/25.2. The facility failed to develop a comprehensive person-centered care plan that reflected Resident #2's diet order for double protein portions as ordered on 06/13/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #82) of 23 residents reviewed for ADLs. The facility failed to ensure Resident #82 had his fingernails cleaned and trimmed on 07/23/2025. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Nurses Cart 300 Short Hall) of 3 carts reviewed for pharmacy services. The facility failed to ensure LVN J, LVN K, and LVN L responsible for Nurses Cart 300 Short Hall, counted all controlled drugs for every shift change on 06/07/2025, 06/08/2025 and 06/16/2025 when LVN I and Surveyor reviewed the count sheets on 07/21/2025. This failure could place residents at risk of not having the medication available due to possible drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (Nurses Cart 300 Short Hall) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure LVN I responsible for Nurses Cart 300 Short Hall, removed medications in unsecure containers from the Nurses Cart on 07/21/2025 when a controlled medication used for pain had broken seals. This failure could place residents at risk of not having the medication available due to possible drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 residents (Resident #15 and Resident #21) of 3 observed for infection control. The facility failed to ensure:1- CNA F changed gloves during incontinent care for Resident #21 on 07/21/2025.2- CNA G performed hand hygiene and changed gloves during incontinent care for Resident #15 on 07/21/25. These failures could place residents at risk for infection and cross contamination of pathogens and illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident did not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provided care and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers/injuries from developing for 1 (Resident #1) of 4 residents reviewed for pressure ulcers/injuries. 1. The facility failed to monitor early signs of a pressure injury (PI) to promote the prevention of pressure ulcer (PU) development to Resident #1's right medial foot and great toe. On 02/07/25, the hospice health aide reported a large blood blister on the right foot and a bruise to Resident #1's right medial foot and great toe to LVN D. LVN D reflected the blood blister on the Weekly Skin assessment dated [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents observed for infection control. 1. The WCN failed to perform hand hygiene and change gloves during wound care for Resident #1. The failure could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity for 5 (Residents #16, #13, #26, #18 and #45) of 10 residents observed in the dining room for dignity. A. Activity Coordinator A was observed standing next to seated Resident #16 and Resident #13 while providing assistance with eating. B. ADON A was observed using a cell phone while sitting at the table with Resident #13 and Resident #26 that required assistance with eating. C. Resident #45 had exposed tubing from her wound vacuum-assisted closure device draped from her ankle, across the side of her wheelchair, to the machine on the back of the wheelchair while sitting at the table in the dining room during lunch. D. Resident #18 was eating their meal for over six minutes before Resident #13, who was sitting at the same table, was provided a tray. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 5 of 8 residents (Resident #'s 45, 18, 17, 9, and 67) reviewed for accommodation of needs, in that: The facility failed to ensure: Residents #'s 45, 18, 17, 9, and 67 had either unwanted facial hairs (Resident #'s 45, 18, and 17 female residents) and or long, dirty, or untrimmed nails (residents #'s 9 and 67). This failure placed residents at risk of not receiving services/care with reasonable accommodation of their needs and preferences, feelings of not being listened to, and depression.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all assistive devices and overbed tables were maintained and free of hazards for three (Residents #9, #18, and #45) of eight residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #9, #18, and #45. These failures could place residents at risk for equipment that was in unsafe operating condition, which could cause injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the following information on a daily basis: (1) Current date. (2) The total number and the actual hours worked by Register Nurses, Licensed Vocational Nurses, Certified nurse's aides, and Resident census at the beginning of each shift in a prominent place readily accessible to residents and visitors. The facility did not post and maintain the required staffing information from May 23, 2024, to May 28, 2024. This failure could place residents and visitors at risk of not knowing how many nursing staff were on duty and the actual hours worked per shift daily.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater for 10 of 80 opportunities during medication pass resulting in an 12 percent (12%) error rate for 5 (Residents #130, #32, #3, #13, and #43) of 8 residents observed for medication pass . 1. MA E failed to administer Resident #130's Potassium 20 meq ( potassium supplement) and Eliquis 2.5mg (blood thinner) in a timely manner. 3. MA E failed to administer Resident #32's Eliquis 5mg (blood thinner) in a timely manner. 4. MA E failed to administer Resident #3's Eliquis 5mg (blood thinner) and Prostat 30ml (protein supplement for wound healing) in a timely manner. 6. MA F failed to administer Resident #13's Carbi/dopa [NAME] doppa 10mg/100mg (for Parkinson diseases) and Ropinirole 0.25mg (restless) in a timely manner. 8. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for four (Resident #130, #32, #3, and #43) of eight residents administered medications by MA E and MA F reviewed for significant medication errors . MA E failed to administer Eliquis (blood thinner) on 05/28/24 as ordered by the physician for Resident's #130, #32, and #3. MA F failed to administer Resident #43's Eliquis 5mg on 05/28/24 as ordered by the physician. This failure placed residents who were ordered to receive blood thinner at risk of not receiving their medications as ordered by the physician, resulting in blood clot and clinical complications.

Inspectors wroteBased on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program for 1 of 1 facility reviewed for QAPI. The facility failed to maintain documentation of QAPI meetings prior to June of 2024. This failure placed residents at risk of maintaining and improving safety and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 7 (CNA A, CNA B, LVN C, CNA D, MA E, and MA F) staff members and 14 of 15 residents (Resident #3, #13, #22, #32, #43, #44, #46, #50, #64, #129, #130, #131, #132, & #150) reviewed for infection control procedures. CNA A, CNA B, LVN C, and CNA D failed to perform hand hygiene after direct contact with Residents #50, #22, #46, #132, #44, and #64 while serving meals on the hallways. MA E failed to disinfect the blood pressure cuff (machine used for checking blood pressure) in between blood pressure checks for Residents #130, #3, and #32. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Gnats were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for 8 (eight doses IV medication) of eight left at the nurse's station, for Floor 200 unsupervised. The facility failed to ensure IV antibiotics were stored in locked compartments and not left at the nurse's station unsupervised. This failure could result in residents having access and ingestion of medications leading to a risk for harm and possible drug diversion.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen where all facility food was prepared. The facility failed to ensure that food was labeled, dated, sealed, and not expired in their kitchen. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents obtain needed dental services, including routine dental services and to ensure the resident was provides the assistance needed or requested to obtain these service for one of two residents (Residents #1) reviewed for dental services. The facility failed to assist in providing routine dental services for Resident #1. Resident #1 was assessed on 11/07/2022 and observed to have dental issues however did not recieve routine treatment which caused Resident #1 to have a tooth abscess with pain. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 (Resident #1) of 6 residents reviewed for abuse/neglect. The facility did not report the allegation of resident neglect to the State Survey Agency within the allotted time frame for Resident #1 who had eloped from the facility on 01/28/24. This failure could place all residents at risk for injuries, abuse, and/or neglect due to not reporting or completing investigations.

Inspectors wroteBased on interviews and record reviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) to incorporate the recommendations and submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal for 1 (Resident #1) of 1 resident's reviewed for Pre-admission Screening and Resident Review (PASRR). Resident #1 accepted PASRR Specialized Therapy Services on 10/5/2023. The assessment was completed on 10/6/2023 and emailed to MDS on 10/9/2023 but was not submitted to the Medicaid Portal. This resulted in services not being approved within the 20-day PASRR time frame. This failure could result in resident's inability to receive specialized therapy services that are needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice for 1 (Resident #52) of 3 residents with a perma-catheter site for dialysis. 1. The facility failed to ensure Resident #52's perma-catheter (an IV line into the blood vessel in the upper chest just under the collarbone used for short-term dialysis treatment) was covered with a sterile dressing. 2. The facility failed to ensure Resident #52 had an order for the care of the perma-catheter and site. 3. LVN C failed to maintain a sterile field while changing a dressing for Resident #52. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications including infection and not receiving proper care and treatment to meet their dialysis needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering and securing of medications for 1 of 1 medication cart (Hall 200 Med-aide cart) reviewed for pharmacy services. The Hall 200 Medication Cart designated Hall 200 Med-aide cart was left unlocked and unattended while medications were being administered to 3 separate residents. The failure could place residents at risk of taking medications not intended for them with adverse outcomes; risk of loss/interruption in receiving medications.